FREE Certified Accreditation Professional Core Competencies Questions and Answers
A Certified Accreditation Professional is performing a gap analysis before an upcoming accreditation audit. What is the primary purpose of this gap analysis?
A gap analysis is conducted to identify areas where current practices do not meet accreditation standards. This allows the organization to address any deficiencies before the external audit. While documentation (D) and corrective actions (B) are part of the process, the primary purpose of a gap analysis is to pinpoint compliance gaps.
In preparing for an accreditation audit, a CAP realizes that employees lack awareness of a new regulatory standard. What is the CAP's best course of action?
CAPs are responsible for educating staff on compliance standards. A training session (B) ensures employees understand and can apply the new regulatory standard, fostering organization-wide compliance. Emailing (A) or posting (D) alone does not guarantee comprehension or accountability, and ignoring the issue (C) could result in audit non-compliance.
During an internal audit, the CAP identifies a department where documentation practices are inconsistent with accreditation requirements. What should be the CAP’s next step?
CAPs should work with departments to correct compliance issues, empowering them to understand and address gaps. Directly reporting to external auditors (A) or ignoring the issue (C) does not resolve the problem. Corrective action requires collaboration rather than unilateral action (D).
A CAP is designing a quality improvement project using the PDCA (Plan-Do-Check-Act) model. What is the main purpose of the “Check” phase in this model?
In the PDCA cycle, the "Check" phase involves evaluating the intervention's results to see if they align with expectations. If successful, the process can move to the "Act" phase for standardization. Planning (A) and implementation (B) occur earlier, and standardization (D) happens in the "Act" phase.
Adjusting audit findings to meet the accreditation requirements
Ethical standards in accreditation emphasize transparency, honesty, and accuracy. Adjusting findings (A), withholding details (C), or omitting issues (D) violates ethical principles and could lead to serious non-compliance issues. Providing clear and accurate reports supports ethical standards.